EARS, NOSE & THROAT (ENT)
Topic: Diseases of the Inner Ear
Lecturer: Dr. Caluag, Jim
Introduction:
If an infection involves the external ear, the common term that we use is
otitis externa
If an infection involves the middle ear, it is known as otitis media
But if an infection involves the inner ear, it is called as labyrinthitis.
 There is no such term as Otitis Interna
LABYRINTHITIS
 Is an inflammatory process that involves both the auditory and
vestibular portions of the labyrinth giving rise to sensorineural hearing
loss and dizziness.
 The inflammation may be localized to involve only the cochlea/auditory
labyrinth, which renders the patient to have hearing loss/deafness.
 It may also localize to involve the vestibular labyrinth which will enable
the patient to complain of dizziness alone.
 The infection of the inner ear could come from other regions or other
structures.
 May spread from adjacent structures such as middle ear or mastoid
(tympanogenic/otogenic labyrinthitis) or from meninges
(meningogenic labyrinthitis)
 Whether it is otogenic or meningogenic form, both disease entities
involve the spread of infection first into the PERILYMPHATIC SPACES
causing extreme damage into the end organs of hearing and balance.
 Another way of the spread of the infection is through the bloodstream
or HEMATOGENOUS spread and this is a special characteristic of viral
inflammations involving the inner ear.
Viral infection invades the labyrinth by the way of stria vascularis
and the infection is called viral endolymphatic labyrinthitis giving
rise to deafness resulting to damage to the end organs of hearing
FORMS OF LABYRINTHITIS
1.) Suppurative/Purulent Labyrinthitis
 Characterized by complete deafness or permanent hearing loss due to
destruction of sensory areas of the labyrinth
 Consists of 3 Stages:
1. Acute Stage (Stormy Period)
 Characterized by the invasion of pus cells
2. Chronic Stage (Latent Labyrinthitis)
 Characterized by fibroblastic proliferation within the
ear fluid spaces
3. Healed Stage (Compensated Labyrinthitis)
 Characterized by ossification of the so called
labyrinthitis ossificans
Acute Stage:
 It starts with the ACUTE STAGE which is characterized by the invasion
of pus cells.
 The acute stage is characterized by a stormy period lasting for 1-2
weeks wherein the vestibular symptoms peaks for the first few days
then gradually subsides after a week.
 When diffuse suppurative labyrinthitis occurs unilaterally, the patient
has severe vertigo and the patient cannot stand or sit upright.
 The patient must lie quietly on the side of the diseased ear which is
completely deaf.
 Slight head and body movements cause the patient to vomit.
 The surroundings seem to spin in the direction from the normal to the
diseased side.
 The patient is very incapacitated to cooperate with tests that suggest a
diagnosis of the basic clinical picture.
 Caloric tests reveals impaired vestibular response
 Labyrinthitis should be differentiated from brain lesions
In labyrinthitis, labyrinthine nystagmus occurs for a few weeks and
then subsides whereas in a brain lesion nystagmus is noted for a
much longer duration
#GrindNation
Strength in knowledge
 Deafness can be assessed by tuning fork testing
 Headache, pain and fever may be absent.
 A stiff neck accompanied by elevated spinal fluid pressure and an
increase in WBC count is not a good sign.
 A unilateral tympanogenic labyrinthitis produces more severe
vestibular upset than a bilateral meningogenic labyrinthitis
This is because the patient is unable to adjust quickly enough to an
acute labyrinthine failure
Chronic Stage
 ACUTE STAGE is followed by the CHRONIC STAGE or LATENT
LABYRINTHITIS characterized by FIBROBLASTIC PROLIFERATION within
the inner ear fluid spaces.
 This chronic stage follows the initial stormy period and usually lasts
from 2-6 weeks.
 By this time, the inner ear is already completely destroyed and deafness
is now complete.
 Incapacitating vertigo has already subsided but a milder vestibular
upset and positional vertigo usually persist.
 Audiologic, and vestibular studies revealed markedly reduced cochlear
and vestibular function
 If bilateral meningogenic labyrinthitis has occurred, there will be
difficulty in ambulation, especially on soft surfaces
Healed Stage
 This is followed by the third stage also known as the HEALED STAGE or
COMPENSATED LABYRINTHITIS which is characterized by
OSSIFICATION OF THE SO-CALLED LABYRINTHITIS OSSIFICANS.
 This period commences after 2-3 months or it takes years before
labyrinthitis ossificans will occur in the membranous labyrinth.
 By this time, the patient has fully compensated the loss of auditory and
vestibular functions as per hearing and caloric testing
 Occasionally, positional vertigo may persist for some months during
this stage.
Management:
 Suppurative labyrinthitis must be actively treated during the ACUTE
STAGE with:
o Bedrest
o Intensive doses of Penicillin/Cephalosporins
o Sulfa drugs and Quinolones
o Rehabilitation in the Healed stage
 If SNHL (sensorineural hearing loss) or vertigo is present, MODIFIED
RADICAL MASTOIDECTOMY must be done to eradicate Mastoid and
Middle Ear Diseases
Complications:
 The most serious stage is the ACUTE STAGE because during this stage,
complications may occur by the spread of the infection to adjacent
regions such as to the internal auditory canal along the nerves and the
vessels or to the cochlear aquiduct.
 Common complication is Septic Meningitis
o Extradural and cerebellar abscesses as well as sinus
thrombosis are possibilities
Page 1 of 5
 EARS, NOSE & THROAT (ENT)
Topic: Diseases of the Inner Ear
Lecturer: Dr. Caluag, Jim

2.) Viral Labyrinthitis  Heavy metals (Gold, Lead, Mercury)

 It is usually seen in patients with measles, mumps and influenza.  Arsenic
 The virus gains entry to the endolymphatic spaces progressing via the  Aniline Dyes
3. Chemicals
stria vascularis and the condition is known as VIRAL ENDOLYMPHATIC  Alcohol
LABYRINTHITIS.  Tobacco
 Vestibular symptoms in VIRAL ENDOLYMPHATIC LABYRINTHITIS  Carbon Monoxide
usually is present during the onset but it subsides after about 2-3 days.  Bleomycin
4. Anti-cancer Drugs
 In viral labyrinthitis, deafness develops quickly and persists as a  Cisplatinum
permanent handicap.  Salicylates (Aspirin)
 Vestibular difficulty is not usually incapacitating for these viral disorders 5. Miscellaneous  Polybrene
so the patient usually does not consult to the doctor early in the course
Agents  Nitrogen mustard
 Quinine
of the disease necessitating a retrospective diagnosis after a time
relapse and the deafness of the patient has already become stable.
 There are certain drugs such as MANDELAMINE – induces tinnitus alone
 Since it is viral, treatment is supportive, symptomatic and non-specific.
 Streptomycin in large doses primarily destroys the Vestibular labyrinth
 It is a self-limiting condition and the patient will eventually recover.
sparing the Auditory Labyrinth although hearing will eventually
deteriorate
3.) Toxic (Serous) Labyrinthitis
It is important to monitor patients on streptomycin therapy for
 Also known as serous or irritative labyrinthitis
systemic diseases
 It is characterized by chemical changes in the inner ear fluid spaces but
there is no pus cell invasion.
Management:
 Serous labyrinthitis could occur after infection of bacterial toxins
 The most effective treatment for ototoxicity caused by drugs is to
involving the round and the oval window or after a meningeal infection.
withdraw from using the drug.
 It could also occur following an ear surgery
 The damage in ototoxicity is permanent.
 Spontaneous vertigo occurring in the presence of middle ear infection
 Hearing loss of the patient may be subjective but may not be supported
indicates serous labyrinthitis.
by clinical findings.
 If nystagmus is present – irritative type (the quick component is towards
 If upon examination, the patient complains of hearing loss bilaterally
the affected ear).
but upon inspection, both ears are normal, hearing loss may be
 There will be hearing impairment.
attributed to the use of such drugs mentioned above.
 Caloric Test – diminished vestibular response
 When vertigo or sensorineural hearing loss develops, erosion of the NEOPLASAMS OF THE INNER EAR
lateral semicircular canal or invasion of the round window membrane 1.) Malignant Lymphoma and Leukemia
is suspected.
 Only involves the temporal bone including the bone marrow of the
 Serous labyrinthitis causes less severe vertigo as compared to petrous apex as well as infiltrations involving the middle ear.
suppurative labyrinthitis in which the patient is severely incapacitated
by the rapid destruction of the end organs. 2.) Terminal Leukemia
 Management:  When leukemia becomes terminal, actual hemorrhage can occur
o Treatment involves administration of large doses of Penicillin involving the inner ear and complete deafness will result.
IV given in the meningitic dose of 2-3 million units per day.
o Symptomatic care which includes sedation and anti- 3.) Acoustic Neuromas
vertiginous drugs may help.
 Some of the most common tumors of the inner ear are tumors involving
o Surgery for more complicated cases
the CEREBELLO-PONTINE ANGLE such as ACOUSTIC NEUROMAS.
If granulation tissue is present in the M.E. or Mastoid, a
complete MASTOIDECTOMY must be done to alleviate the
Neoplasms
source of infection in the inner ear
 All patients complaining of dizziness, ringing of the ear, unilateral SNHL
and facial paralysis should have audiometric test for pure tone, a
OTOTOXICITY
careful caloric examination and radiologic examination of the
 Hearing loss (deafness and ringing of the ear) may result from
temporal bone including MRI and CT scan
detrimental effects of certain substances that involves the inner ear.
 The tumor can involve the vestibular nerve causing dysfunction
Agents Responsible for Causing Ototoxicity although true whirling vertigo is absent
 Aminoglycosides  There is generally a feeling of disequilibrium associated with other
 Chloramphenicol neurologic symptoms
 Ristocetin  Characteristic feature of an acoustic tumor – inability of the patient to
1. Antibiotics
 Macrolides understand speech (RECEPTIVE APHASIA)
 Pharmacetin  Once a tumor is suspected, a diagnostic test for auditory fatigue in
 Polymyxin B Sulfate
tumors of the internal auditory canal should be requested –
 Ethacrynic acid
CLIVOGRAM (Pantopaque Myelography) of the internal auditory canal
2. Diuretics  Furosemide
and posterior fossa
 Mannitol
Management:
 Removal of the tumor depends upon its biologic nature, location, size,
and symptom-causing disabilities
 Surgery varies from Middle Cranial fossae or Posterior Cranial fossae
approaches

#GrindNation Page 2 of 5
Strength in knowledge
 EARS, NOSE & THROAT (ENT)
Topic: Diseases of the Inner Ear
Lecturer: Dr. Caluag, Jim
TRAUMA
 Hearing loss may result from several forms of trauma such as noise
exposure, explosive blasts and blows to the head and the ears.
 The fact that noise exposure can produce hearing loss has been known
for a long time as Boilmaker’s deafness but lately a significance has
been given to minor degrees of such hearing losses.
 In general, an 85 decibel of noise exposure is injurious.
 Hearing loss caused by noise exposure results in extreme damage
involving the organ of Corti.
 The documented time of exposure to 80 decibel of noise is 54 minutes.
 If the noise is concentrated at 50 decibels, earphones should be used
for less than 2 hours.
 If a person is exposed to a 50 decibel noise for 6 hours, there is a
residual effect in the acoustic nerve and noise induced hearing loss can
develop.
 Animal research indicates that exposure to high intensity sounds for
long periods causes varying degrees of degeneration from slight
changes in the hair cells to complete degeneration and destruction of
the Organ of Corti.
Factors Affecting Noise-Induced Deafness:
 Overall level of noise
 Frequency composition of the noise
 Daily distribution of the noise
 Total time of exposure to the noise
Management:
 The most effective method of treatment is to avoid noise.
 The second most effective method of treatment is to reduce noise
exposure by wearing ear defenders (ear muffs).
Ear defenders - generally provides only up to 35 decibels of
protection. If the sound is intense enough, it can still be injurious
FRACTURES OF THE TEMPORAL BONE
 Bleeding caused by fracture cannot be controlled or treated by
applying pressure.
 Manifests as a profusely bleeding ear
 Any form of instrumentation must not be done unless sterile
instruments will be used because the injury might be further
contaminated.
 Fractures of the temporal bone may give rise to hearing loss and
dizziness.
1.) Longitudinal Fracture
 Considered to be less severe in causing deafness as compared to the
horizontal type
 May give rise to a concussion fracture in the inner ear resulting to
sensorineural hearing loss and usually there is a delayed onset of facial
paralysis that would occur at about 24-48 hours
 It is managed conservatively with steroid therapy and rehabilitation.
2.) Horizontal or Transverse Fracture
 The fracture line will extend to involve the internal acoustic meatus
going into the bony labyrinth.
 The bony labyrinth cannot heal by primary intention so secondary
inflammation arises in the inner ear which gives rise to a profound
sensorineural hearing loss and a dizziness together with an abrupt onset
of facial paralysis.
 It is radically managed by doing mastoidectomy under general
anesthesia on an indication of facial nerve decompression.
#GrindNation
Strength in knowledge
SENSORINEURAL HERING LOSS
 Quite a common complaint
 It is a permanent and progressive disorder although there are cases of
sensorineural hearing loss that can be reversible if the disease is
identified and treated early.
 Examples include endolymphatic hydrops or Meniere’s Disease, or
other types of fluctuant hearing losses due to allergies, vascular
problems, serous or toxic labyrinthitis and ototoxicity.
 Hearing loss may also result from syphilis and hypothyroidism and
proper treatment for the systemic disease will eventually result to
hearing improvement.
 In the case of syphilis, the disease process may be localized to involve
only the inner ear and a trial period of high doses of Penicillin therapy
given intravenously will lead to improvement of the hearing function.
 The main hope in dealing with sensorineural deafness lies in prevention.
 When permanent sensorineural hearing loss is found, it is important to
provide follow up to the patient in order to assess the progression of
the hearing loss.
 Audiology may be helpful in providing rehabilitation to the patient in
relation to the patient’s problems at work or in any social situation.
 Hearing can be improved through amplification following hearing aid
education.
 Hearing aid must be recommended by a professional in order for the
patient to have satisfactory results.
 It is also important to teach patients lip reading along with hearing
amplification in order for them to function normally in the society.
TINNITUS
 Also known as ringing of the ears
 A sound experience perceived by the patient originating with himself
 Tinnitus heard at the center of the head indicates that the origination
in the two ears is of the same pitch and the loudest of the experience
practically arises from the neural apparatus of the central nervous
system.
1.) Objective Type
 The tinnitus is heard not only by the patient but also by the examiner
upon auscultation of the external auditory canal and the examiner will
hear a sound which is usually described as a bruit type of tinnitus.
 Causes of Objective Tinnitus:
o Altered sound conduction
This is associated with obstruction to sound conduction
seen in impacted cerumen, a middle ear fluid or a simple
otosclerotic fixation of the stapedial footplate described as
a hollow sea-shell type of a sound due to masking of a well-
functioning cochlear neural apparatus from the covering
effect of ambient sound
o Vascular pathology
When a middle ear pathology exceedingly vascular as in a
carotid body-like tumor, a pulsing sound of blood flow can
be heard as a troublesome tinnitus with exceedingly
vascular and extensive otosclerotic foci
o Clonic contraction of middle ear muscles
When the tensor-tympani and the stapedius develops
clonic contraction, the result is a flutter or a machine gun-
like sound in the ear. Nervous tension, stress, and fatigue
plays a part
o Cervico-cranial vibrating phenomena
Vibratory phenomena perceived as an unpleasant sound
experience if the loudness is above the reception threshold
of the cochlear neural apparatus
Page 3 of 5
 EARS, NOSE & THROAT (ENT)
Topic: Diseases of the Inner Ear
Lecturer: Dr. Caluag, Jim

Causes of Objective Tinnitus continued….. VERTIGO

o Patent Eustachian Tube  A patient with dizziness oftentimes comes to the clinic complaining of
Produces rushing sounds of air during respiration and lightheadedness, giddiness, imbalance or disequilibrium.
perceived as autophony by the patient, rapid weight loss  Vertigo is described as a sensation or hallucination of a twirling
and use of birth control pills are frequent factors motion.
 It is important to determine the cause of dizziness in order to establish
treatment and diagnosis.
2.) Subjective Type
 Tinnitus is heard only by the patient and is the most frequent type. Causes of Vertigo
 Causes of Subjective Tinnitus:  Refraction errors  Anemia
o Pathologic alterations in the cells of the end organ of Corti  Acoustic neuroma  Pregnancy
Pathologic disturbance in the hair cells on the basal turn of  Glaucoma  Postural hypotension
the cochlea results to high-pitched tinnitus described by  Brain lesion (tumors, infection  Chronic otitis media
the patient sounding like a bell ringing or trauma)  Hypertension
 Locomotor ataxia  Labyrinthitis (any form)
o Physical distortion of the cochlear sensory system  Tabes dorsalis  Toxic exposure
Creates a discordant cacophonic sound experience which is  Chronic alcoholism  BPPV
exceedingly distressing occurring in Meniere’s disease in  Multiple sclerosis  Vertebra-basilar insufficiency
which hearing impairment occurs first as lack of  Diabetes mellitus  Labyrinthine concussion
discrimination as a result of frequency distortion  Migraine  Meniere’s disease
 Hypoglycemia  Temporal bone fractures
o Endolymphatic hypertension  Seizures (grand mal)  Vestibular neuronitis
Results from functional vascular change in the terminals of  Cerebello-pontine angle lesions  Dehydration
the cochlear vascular system usually occurring in patients  Intracranial space occupying  Electrolyte imbalances
with fundamental endocrine imbalance lesions

o CNS disorders
A neural apparatus central to the cochlea can be the origin
of tinnitus. Cerebello-pontine angle lesion affecting the 8th
nerve trunk directly generates a minor high pitched tinnitus
not usually localized to the ear
Treatment for Tinnitus:
 Correction for a known cause is the most effective positive treatment
since therapy can be aimed specifically.
 A bedside clock radio, loudly ticking alarm clock or a fan provides
ambient noise to mask the ringing at bedtime.
 Tranquilizers and sedatives may be initially used but should be
discontinued as the patient becomes more adjusted to the symptoms.
 The patient should be informed that there are no miracle drugs or
surgical procedures for tinnitus.
 If there is an accompanying hearing loss, wearing hearing aids will
increase ambient sound to mask the tinnitus.
 Any disorder that causes unilateral reduction in vestibular function may
cause vertigo
 The best way to establish whether vestibular activity is reduced,
vestibular function is measured by Caloric Test done by tilting the
patient’s head 60 degrees backward and irrigating the ear with cold
water, a horizontal nystagmus of 1-3 minutes duration occurs with fast
component towards the opposite side
 Most patients have very active response and the characteristic of
nystagmus must be noted
There are 3 characteristic of nystagmus exhibited by the patient:
1. Vertical nystagmus – indicates brain lesion
2. Horizontal nystagmus – indicates that there is
labyrinthine lesion
3. Rotary nystagmus – means that the vertigo is systemic
in origin
 Vertigo due to CENTRAL DISORDERS – central vertigo may be due to:
o Multiple sclerosis
o Acoustic neuromas
o Seizures
o Basilar insufficiency
o Vascular accidents
 Several conditions affect the vertebral basilar arterial system and may
cause vertigo

Cervical Spondylitis
 May cause compression on the Basilar Artery resulting to vertigo
 Another condition is insufficient blood supply to the basilar system
 Chronic ischemia of the vertebral basilar arterial system due to
Atherosclerosis produces vertigo

#GrindNation Page 4 of 5
Strength in knowledge
 EARS, NOSE & THROAT (ENT)
Topic: Diseases of the Inner Ear
Lecturer: Dr. Caluag, Jim

Benign Paroxysmal Vertigo (BPPV) Other Management of Meniere’s Disease:

 Condition usually seen in adults when the patient’s head is placed in a
certain provocative position
 A patient with this problem has nystagmus towards the affected ear.
 Most evidence to date locates the causative lesion to involve the utricle.
 May follow trauma or may appear spontaneously
 Hearing and Caloric Testing are Normal
 Management:
o Reassurance that the condition is not serious
o Antiemetics and sedatives can help
 If the patient has INCAPACITATING VERTIGO in spite of extended
medical treatment, LABYRINTHECTOMY is done in which the inner ear
contents are surgically removed and surgical drainage of the
Endolymphatic sac to reduce swelling
 Another is IV administration of high doses of streptomycin which will
primarily destroy the vestibular labyrinth, although hearing function
should be well monitored

Vestibular Neuronitis
 Also known as epidemic labyrinthitis because it sometimes seems to
occur in epidemic form
 Patient presents with intermittent vertigo.
 Examination shows normal hearing but with a reduced caloric reaction
 Thought to be due to a virus that attacks the ganglion of the vestibular
nerve but attacks the whole vestibular labyrinth
 Thought to be due to the activation of Human Herpes simplex virus
 Medications are supportive but not specific.
 A self-limiting

Vertigo caused by Tumors

 Hearing loss and vertigo can be caused by tumors affecting the middle
or inner ear.
 Tumors of the temporal bone may be classified as primary or
secondary.
Primary Tumors:
 Glomus jugulare tumor of the middle ear
 Chemodectomas
 Squamous cell carcinoma of the ear canal and the middle ear
 Acoustic neuromas

 Management:
o Treatment after an early diagnosis is preferably surgical.
o Radiotherapy is a useful pre and post-operative adjunct
therapy.

MENIERE’S DISEASE (ENDOLYMPHATIC HYDROPS)

 There is an excessive amount of endolymph being produced which
results to an increase in the volume of the endolymph resulting to
swelling of the membranous labyrinth that will eventually cause
dizziness and deafness (sensorineural hearing loss).
 The cause is probably related to a disturbance in the osmotic pressure
gradient at the blood-endolymph barrier.
 Triad Symptoms of Meniere’s Disease:
o Tinnitus (Subjective)
o Deafness (SNHL)
o Vertigo (Episodic)

 Management:
o Diuretics are given to reduce the swelling of the membranous
labyrinth.
o It has the same principle of management with glaucoma.
o Sedatives
o Central vasodilators
o Antiemetics

#GrindNation Page 5 of 5
Strength in knowledge